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270 Cards in this Set
- Front
- Back
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what injuries must be suspected from a side on collision? |
lateral neck sprain, lateral contusion, lateral flail segment, C spine fracture, fractured pelvis, fractured spleen, liver, pneumothorax, traumatic aortic dissection. |
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what is the AMPLE history |
allergies medications past medical history/pregnancy last ate events/environment |
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what things should we look for in the neck after trauma? |
midline c-spine tenderness. Midline trachea, subcutaneous emphysema, carotid auscultation for bruits and dissection. look for the seatbelt mark. palpate the laryngeal cartilages. |
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what is the cause of most major cervical vascular injuries? |
penetrating trauma |
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who should manage a foreign body which penetrates the platysma?
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surgeon or experienced clinician |
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how should we examine the chest? |
look: for obvious deformity and seat belt sign listen: reduced breath sounds -pneumothorax feel: sternal pressure and clavicles. percussion and CXR for haemothorax and effusions reduced pulse pressure and distant heart sounds may indicate tamponade. |
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what is the important point regarding children and thoracic injury? |
they often sustain significant injury to intra-thoracic structures without evidence of damage to thoracic MSK structures. |
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how effective is abdominal examination at detecting intra-abdominal trauma? |
repeat examinations are required and a normal initial examination does not preclude trauma. abdominal exam may also be hindered by pain from the pelvic region if there is a fracture. |
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what are the indications for peritoneal lavage? |
unexplained hypotension, neurological injury, impaired sensorium secondary to alcohol and/or other drugs and equivocal abdominal findings. |
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when would CT abdomen be more appropriate than peritoneal lavage? |
CT is less invasive and more appropriate if the patient is haemodynamically stable. |
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what should be looked for on vaginal and rectal exams? |
blood in the rectum or high riding prostate. Blood in the vagina if there has been a pelvic fracture. |
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in what ways may a pelvic fracture be suspected? |
haematoma over the iliac wings, pubis, labia and scrotum. Also palpate the pelvis and feel for anterior-posterior dislocation and pain. |
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what is a good way to hand over? |
M - mechanism and time of injury I - injuries found and suspected S - symptoms and signs T - treatment initiated |
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how does alcohol affect temperature regulation? |
alcohol can cause vasodilation and hence more rapid loss of temperature. |
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what are the signs of laryngeal fracture? |
hoarseness, subcutaneous emphysema and palpable fracture. |
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what are the options if intubation fails in the setting of laryngeal trauma? |
surgical airway, tracheostomy or (less preferred) cricothyroidotomy may be life saving. |
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which clinical features suggest hypoxia and hypercarbia? |
agitation suggests hypoxia and obtundation suggests hypercarbia. |
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which visual features may suggest a difficult airway |
small mouth. Large overbite, facial trauma |
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which criteria would suggest a difficult airway? |
L - look externally E - examine 3-3-2 (3 fingers open mouth, 3, hyoid to chin, 2 laryngeal notch to mouth floor) M - Mallampati O - obstruction - epiglottis, trauma, abscess N - neck mobility |
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what are three echo signs of tamponade? |
RV diastolic collapse, RA systolic collapse, exaggerated TV/MV inflow >25% on M mode. |
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what is the advantage of performing a chin lift? |
there is less risk of C-spine flexion, so it is useful in trauma patients. |
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what are three examples of BIADs? |
Blind insertion airway devices. LMA, LTA and combitube. |
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what is an LTA? |
laryngeal tube airway. similar to LMA, but has two balloons, proximal and distal. proximal sits in the pharynx, distal in the oesophagus. air is released into the hypo pharynx and thus forced into the airway. |
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what is a combitube? |
double lumen LTA. It can enter the oesophagus and distal and proximal balloons inflate and work similar to LTA. It can enter the airway and then air can be attached to the laryngeal lumen. in this case, the proximal balloon would be inflated. |
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what is the definition of a definitive airway? |
cuff beneath the vocal cords. |
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which of the following is an absolute contraindication to nasal intubation? a) cribriform plate fracture b) apnea c) frontal sinus disruption d) maxillary arch fracture e) sinusitis |
b. apnea. endotracheal nasal intubation requires a patient who is spontaneously breathing. |
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what are the indications that a boogie is within the airway? |
feel the cartilage rings, rotates left or right when entering the left or right main bronchus. blocked at the bronchial tree. |
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what is the physiological significance of end tidal CO2? |
none, other than the airway has been intubated. |
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what is the best way to confirm the correct position of the tube? a) end tidal CO2 b) visualising the tube passing through the cords c) rise and fall of the chest d) Chest XR e) absence of borborygmi |
d) Chest XR. While capnography confirms that the tube is in the airway, it cannot confirm that the tube is in too far and ventilating the right main bronchus only. Hence overall position best assessed with CXR |
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what is the dose of succicyl-coline? In whom must we be careful of its use? |
1-2mg/kg. Hyperkalaemia |
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what is the problem with etomidate? |
not available in Australia. Can cause adrenal suppression which is particularly bad in shocked patients. |
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how does ketamine work ,when is it used and what is the dose? |
1-2mg/kg in RSI 0.25-0.5mg/kg in shocked patients. least effect on the CVS. central inhibition of noradrenaline re-uptake. |
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what are the indications for cricothyroidotomy? |
unable to pass laryngoscope through the cords, glottic swelling, laryngeal fracture, severe oropharyngeal oedema. |
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what sort of patients can be oxygenated with a needle cricothyroidotomy? |
only patients with good lung function and they may only be so for 30 to 45 minutes. |
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what are the risks of jet insufflation in patients with complete foreign body obstruction of the glottic area? |
high pressure may expel impacted material into the hypo pharynx where it can be removed more readily. However, barotrauma including tension pneumothorax may ensue. |
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below what age is surgical cricothyroidotomy not recommended and why? |
a patient under 12 years of age. It is easy to damage the cricoid cartilage which is the only support for the trachea. |
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why is the novel percutaneous tracheotomy not recommended in trauma settings? |
it requires neck hyper-extension as well as placement of a heavy guide wire. This is not appropriate in a trauma setting. |
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name three setting in which pulse oximetry is not useful. |
1. poor peripheral perfusion 2. carbon monoxide poisoning 3. meth-haemoglobinaemia because it is impossible for oximetry to distinguish between carboxyhemoglobin and meth-haemoglobinaemia. |
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does anaemia or hypothermia affect oximetry? |
profound anaemia (Hb less than 50) and severe hypothermia <30 degrees C, reduces reliability. |
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what is a practical tip to help remind the operator not to take too long with intubation? |
the incubator should take a large breath in and hold and when he needs to breathe again, the attempt should be stopped and the patient re-bagged. |
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what are two problems with etomidate as an indication agent and what is the dose? |
0.3mg/kg. adreno-cortical suppression and not available in Australia. |
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name two indication agents and their dose? |
ketamine 1-2mg/kg propofol 1.5-3mg/kg |
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which induction agent would be best with raised ICP? |
fentanyl 3micrograms per kg as pre-treatment before giving etomidate or some other induction agent (ketamine) |
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which induction agent should be used in a shocked patient? |
ketamine |
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what are three factors contributing to myocardial contractility? |
HR, SV and myocardial contractility. |
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what drives venous return to the heart? |
the relationship between venous volume and pressure. This describes capacitance. |
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what is the effect of blood loss on the venous return? |
there is less of a gradient between the venous volume and venous pressure, hence less venous return. This in turn means less myocardial contractility. |
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what is the earliest measurable sign of shock? |
tachycardia. |
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which substances are released by the endocrine system in shock and what are their effects? |
endogenous catecholamines increase peripheral vascular resistance, increases diastolic BP has little effect on organ perfusion. histamine, bradykinin and beta-endorphins, prostanoids and cytokines increase micro vascular permeability. |
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what is the effect of reduced oxygen perfusion? |
initially there is compensation with anaerobic metabolism. However, this then progresses to reduced ATP production, reduced membrane stability and pro-inflammatory mediator release setting the stage for end organ damage and MODS. |
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what is the role of vasopressors in shock? |
they have no role in hemorrhagic shock as they worsen tissue perfusion. |
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how does the definition of tachycardia change with age? |
>160 as an infant >140 as a pre-schooler >120 as an child/teenager >100 in an adult |
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what is the best strategy for managing tamponade? |
thoracotomy. If this is not possible, then pericardiocentesis. |
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what are the clinical features of tension pneumothorax? |
reduced breath sounds, tracheal deviation, subcutaneous emphysema, distended neck veins, respiratory distress. |
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what are the clinical features of neurogenic shock. |
neurogenic shock often caused by spinal cord injury. there is often trauma to the trunk. features include normal pulse pressure, hypotension without tachycardia as the sympathetic response is blunted. |
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how is blood volume calculated in adults? |
based on their ideal body weight as there may be a significant over-estimation in obese patients. |
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what clinical features are found in class II shock? |
Bloods loss of 750-1500mls, tachycardia, narrowed pulse pressure (systolic tends not to drop much. most can be resuscitated with crystalloids. the clinical picture is affected by factors such as age, comorbidities and mechanism of injury. |
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how do patients in class III shock present? |
tachycardic, hypotensive, poor peripheral perfusion. Mental obtundation. peripherally shut down. most patients in this category will require packed red blood cells and fluids. |
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what percentage of the body weight is generally within the circulation? |
for adults 7%, for children 8-9% |
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how much is one unit of blood? |
generally 500ml. |
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how much blood is lost from a tibia or humerus fracture? |
750mls |
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how much blood can be lost from a femoral fracture? |
1.5-2L |
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ABCDEFGU of trauma |
airway breathing circulation Disability - Neuro Exposure (hypothermia) (Don't ever) Forget (glucose) Gastric distention - increased vagal tone can cause unexplained hypotension in a patient. that with NGT. increased risk of aspiration Urinary catheterisation |
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what are the absolute contra-indications for urinary catheter insertion in males in trauma? |
blood at the urethral meatus, high riding, mobile or non-palpable prostate in males. requires radiographic examination prior to insertion if required. |
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how does flow relate to cannula size? |
pouiselle's law, proportional to the fourth power of the radius and inversely proportional to the length. |
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what is the role for IO needles in children under 6? |
these must be attempted before central line insertion in these patients if peripheral access is difficult. |
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what bloods should be taken in trauma? |
FBC, U&Es, LFTs BC cross match toxicology screen pregnancy test (women child bearing age) ABG |
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what is a caveat to high fluid resuscitation? |
if the original site of bleeding has not been controlled, then there may be repeat bleeding and lethal coagulopathy, metabolic acidosis and hypothermia with activation of the inflammatory cascade. |
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where should you look for blood? |
on the floor chest abdomen pelvis femur |
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what are suitable urine outputs? |
0.5ml/kg in adults, 1ml/kg in children and in infants under the age of 1 year 2ml/kg |
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what can be used to treat metabolic acidosis secondary to hypovolaemic shock? |
sodium bicarbonate |
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do rapid responders after shock require surgical assessment? |
Yes |
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what is the best way to prevent hypothermia? |
warm fluids prior to infusion |
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what are three was to replace blood? |
cross matched O positive blood warming fluids autotransfusion - blood collected from thoracsostomy bag massive transfusion |
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what is a massive transfusion? |
more than 10 units blood within the first 24 hours of admission. |
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do patients receiving transfusions require calcium supplementation? |
No. |
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How reassuring is an increase in blood pressure in response to shock? |
It may be reassuring, however, does not necessarily mean an increase in CO. Ohm law V.=I.R. BP=COxPVR. Vasopressors may increase PVR, hence BP without an increase in CO. |
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Explain how elderly people differ in the their response to shock and why. |
1. reduced receptor response to catecholamines 2. reduced cardiac compliance 3. reduced ability to increase HR 4. nutrient deficient and baseline dehydrated 5. mat be beta-blocked which masks tachycardia response. 6. atherosclerosis makes end organs more sensitive to reduced blood flow. |
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what changes are seen in athletes? |
they can increase CO 6 fold and usual symptoms may not be seen even after significant blood loss. |
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how do various medications affect shock? |
beta blockers and calcium channel blockers later haemodynamic response. insulin overdosing may produce hypoglycaemia long term diuretic therapy may produce hypokalaemia NSAIDs may affect platelet function |
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what is the effect of hypothermia in shock, where is a good place to measure it and how does alcohol affect hypothermia? |
worsens coagulopathy, core temp best measured in the bladder or oesophagus. Alcohol will worsen hypothermia because of peripheral vasodilation. |
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in what patients is CVP monitoring particularly useful? |
pacemaker patients who do not increase their HR in response to shock. |
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which group of shocked patients should be considered for early ICU referral? |
elderly patients and patients with non-hemorrhagic shock. |
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what is the most precise measure of cardiac function? |
the relation between end diastolic volume and stroke volume. RA pressure and CVP are insensitive markers at best. |
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how useful is CVP as a marker of blood volume? |
more useful as a trend measure. May be high with volume deficit if there is pulmonary hypertension, COPD, reaped fluid replacement and generalised vasoconstriction. minimal rise in CVP suggests the need for more aggressive fluid replacement and re-evaluation of bleeding site. abrupt elevation suggests over transfusion of fluid of cardiac dysfunction. |
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what are the complications of central line placement? |
thrombosis, infection, embolism, vascular damage, arrhythmia, pneumothorax, nerve dysfunction. |
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what things need to be considered in a patient who does not respond to shock? |
1.undiagnosed source of bleeding 2. tamponade 3. tension pneumothorax 4. sepsis 5. ventilatory problems 6. myocardial infarct 7. gastric distension 8. diabetic acidosis 9. hypoadrenalism 10. neurogenic shock |
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what are the assessments necessary for diagnosis of intra-abdominal bleeding in a female? |
distended abdomen, uterine lift, DPL ultrasonography necessary and vaginal exam. |
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describe a systematic interpretation of an AP pelvic XR. |
1. pubic symphysis no more than 1cm 2. pubic rami in tact superior and inferior 3. femoral head, neck and acetabulum 4. symmetry of the ilium and sacroiliac joints 5. symmetry of the sacral foramina by evaluating arcuate lines 6.fractures of transverse processes of L5 |
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describe some techniques to reduce blood loss from pelvic fractures. |
1. avoid excessive manipulation of he pelvis 2. internally rotate the lower legs to close an open book fracture. 3. apply external fixation devices early 4. apply skeletal limb traction 5. embolism pelvic vessels with angiography 6. early orthopaedic consult. 7. sandbags under buttocks if no indication of spinal injury and other techniques not available. 8. pelvic binder 9. transfer to definitive care facility |
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what is the treatment for an open pneumothorax? |
place an occlusive dressing over the open wound and tape it down over three edges. This way it acts as a flutter valve inspiration does not permit inflow, expiration allows air to escape from the chest cavity. Open pnuemothoraces are generally only problems if the diameter of the defect is more than 2/3 of the diameter of the trachea in which case air flows into the cavity preferentially through the open defect. |
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what feature suggest massive haemothorax? |
shock with reduced breath sounds and percussion dullness. |
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how is a massive haemothorax managed? |
1. Transfusiono f blood 2. chest level of nipple just anterior to midaxillary line 3. collect the blood for auto-transfusion 4. thoracotomy required if greater than 1500mls present initially or continual bleeding (greater than 200ml/hr for 2-4 hours), also based on clinical status. 5. penetrating chest trauma anteriorly medial to nipple and posteriorly medial to scapular may require thoracotomy. |
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what are the causes of PEA? |
tamponade, tension pneumothorax, profound hypovolaemia and cardiac rupture. |
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how accurate is fast Scan for the presence of pericardial fluid? |
90-95% accurate in the hands of experienced operators. |
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how is tamponade managed? |
1. fluid initially will raise CVP and improve cardiac function transiently 2. pericardiocentesis will temporarily improve symptoms 3. if positive for blood, then surgery will be required at some point to examine the heart. However, often myocardial injuries are self sealing. 4. the blood may have clotted in which case, the patient requires immediate transfer to a cardiothoracic centre. |
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which patients are candidates for resuscitative thoracotomy? |
patients with penetrating chest trauma and organised electrical activity. |
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what can be achieved with resuscitative thoracotomy? |
1. evacuation of pericardial clot 2. direct control of exsanguinating intrathoracic haemorrhage 3. open cardiac massage 4. cross-clamping of the descending aorta to promote blood flow to the brain and heart. |
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what is the most common cause of simple pneumothorax from blunt injury? |
lung laceration leading to air leakage into the pleura. |
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what are the consequences of there being an unrecognised pneumothorax at the time of say a diagnostic laparotomy? |
positive pressure ventilation could convert a simple pneumothorax to a tension pneumothorax. |
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what are the causes of a haemothorax (<1500ml) |
blunt or direct trauma to the lung, intercostal vessels or internal mammary artery. thoracic spine fractures may also produce a haemothorax. |
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what are the long-term risks with simple haemothoraces? |
the blood can clot causing lung entrapment and become infected leading to empyema. |
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what are the complications of pulmonary contusion? |
hypoxia and respiratory distress may develop over hours rather than immediately. if sats are less than 90% on RA or if there is underlying COPD or renal disease, then the patient may require intubation and ventilation. careful monitoring of oxygenation, fluid status and ventilation is required, often over several days.
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what is the commonest site of injury for trachobronchial injuries? |
1 inch from the carina |
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how do patients with a tracheobronchial injury present? |
haemoptysis, subcutaneous emphysema, tension pneumothorax. in complete re-expansion of the lung following tube placement. |
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how should tracheobroncial injuries be managed? |
initially may require urgent intubation of the opposite main bronchus for adequate ventilation. |
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what are the ECG features seen in blunt myocardial injury? |
multiple PVCs, AF, bundle branch block (usually right) and ST segment changes. |
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how should a patient with blunt myocardial injury be managed? |
if they have ECG abnormalities they need to be omitted for 24 hours. |
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what are the XR features of aortic rupture? |
1. widened mediastimun 2. obliterated aortic knob 3. deviation of the trachea to the right (in a patient with left sided aortic arch) 4. depression of the left main stem bronchus (see above) 5. obliteration of the space between the PA and aorta (obscuration of the PA-Aortic window) 6. deviation of the oesophagus to the right 7. widened paratracheal stripe |
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what is the management of aortic rupture? |
many patients die. However survival is possible, if there is a contained haematoma. helical CT is necessary and if findings equivocal aortography required. sensitivity is about 100% with helical contrast-enhanced CT. |
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what is the XR appearance of a traumatic diaphragmatic injury? |
raised hemidiaphragm. If left side is suspected to be ruptured, then place NGT and appearance on XR within the stomach confirms the diagnosis. CT scan may be performed. Peritoneal lavage useful and then treatment is with direct repair. |
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what is the risk with undiagnosed diaphragmatic injuries? |
respiratory compromise or entrapment and strangulation of peritoneal contents. |
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what are some precautions with subcutaneous emphysema? |
chest tube in place before intubation |
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what mortality is associated with scapula fractures? |
35% |
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what other injuries must be suspected if you see a rib fracture on CXR? |
pneumothorax and pulmonary contusion. |
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respiratory distress without XR findings |
CNS injury, aspiration, metabolic cause, asphyxia |
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fracture of first three ribs - associated injury? |
great vessel injury |
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scapular fracture - associated injury? |
great vessel injury, sternal fracture, thoracic spine injury. |
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persistent large pneumothorax after chest tube insertion - associated injury? |
bronchial tear |
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ruptured diaphragm - associated injury? |
abdominal visceral injury |
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mediastinal air - associated injury? |
oesophageal disruption, tracheal injury, pneumoperitoneum |
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how do you know with pericardocentesis whether you have gone too far? |
either with US guidance or there will be significant ST changes if the myocardium is ruptured. If these occur pull out before proceeding. |
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what are the complications of pericardiocentesis? |
aspiration of ventricular blood, laceration to ventricle, damage to coronary vessels, damage to great vessels. VF, pneumothorax |
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what is an example of a bucket handle injury in the abdomen? |
deceleration injury can impact the small bowel |
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what are the most frequently injured organs in blunt trauma? |
spleen (40-50%), liver (35-45%) and small bowel (5-10%) |
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what are the commonest organs damaged after knife attacks to the abdomen? |
liver (40%), small bowel (30%), diaphragm (20%) and colon (15%) |
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what are the commonest injuries after gunshot wounds to the abdomen? |
smal bowel (50%), colon (40%), liver (30%), abdominal vascular structures (25%) |
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what injuries must be suspected in a lap seat belt restraint belt? |
mesenteric damage (Bucket handle), rupture of small bowel or colon, thrombosis of iliac vein or artery, chance fracture of lumbar or thoracic spine, pancreatic or duodenal injury. |
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what injuries must be suspected after shoulder harness restraint? |
innominate, vertebral or carotid artery thrombosis. fracture or dislocation of C spin, rib fracture, pulmonary contusion, rupture of abdominal viscera |
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Air bag deployment - associated injuries? |
corneal abrasion, facial fracture, C spine fracture, thoracic lumbar vertebral fracture. |
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what clinical features suggest pelvic fracture? |
leg length discrepancy without obvious fracture, high riding prostate on PR, blood at the tip of the urethra, scrotal haematoma. |
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explain how to test for pelvic instability? |
pelvic spring test. the unstable hemipelvis will migrate cephalad and rotate towards and so can be pushed back into position with this compression, distraction manoeuvre. |
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how do you test for posterior ligament disruption? |
the hemipelvis can be pulled caudally as well as pushed cephalad. |
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what other examinations are important is pelvic injury is suspected? |
urethral, rectal perineal exam, vaginal and gluteal exam. |
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how likely is it that a gluteal penetrating injury will injure the abdominal cavity? |
50% chance of gluteal penetration piercing into the abdominal cavity. |
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what is the role of a urinary catheter in abdominal trauma? |
after PR has been performed, urinary cauterisation is important for relieving retention, decompressing the bladder before DPL and allowing for monitoring of urinary output. |
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what should be done before inserting a catheter? |
rectal exam, perineal examination. if high riding prostate or scrotal haematoma, blood at the meatus is found, then retrograde urethrogram must be performed before insertion of IDC. |
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what is the sensitivity of DPL for peritoneal bleeding? |
98% |
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when is DPL useful? |
in patient who have haemodynamic compromise with suspected abdominal trauma. In haemodynamically stable patients for whom USS and CT are not available. |
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what are the contra-indictions for DPL? |
previous abdominal operations, morbid obesity, advanced cirrhosis. supra-umbilical approach preferred for those with pelvic fractures. in pregnant patients, open suprafundal approach should be used. |
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what is a positive DPL? |
free blood, GI contents, vegetable fibres and bile all mandate laparotomy. if nothing coms out, then 1000ml of warm saline is injected into the abdominal cavity. a sample of this fluid is then sent to the lab, gram stained and analysed. greater than 100,000 RBCs or greater than 500WBC or gram stain with bacteria present is a positive test. |
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when should a CT abdomen be done in patients with abdominal trauma? |
if they are haemodynamically stable. |
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explain how a urethrogram is performed. |
in patients suspected of urethral injury, insert 8 French catheter into urethra and secure in the metal fossa with 1.5 to 2ml saline injection. 30-35ml of undiluted contrast is flushed through. AP radiograph taken and positive is if there is reflux into the bladder. |
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explain the utility of a cystogram. |
contrast is injected into the bladder and drainage is observed. useful to detect a ruptured bladder. |
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how does an intravenous pyelogram work. |
used when CT is not available and urethral injury suspected. 200mg/kg of iodine. involves 100ml injection of 60% iodine. Calyces can be visualised after 2 minutes. non-visualisation represents absent kidney, thrombosis, avulsion of renal artery or massive parenchymal disruption. |
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what is a major diagnostic limitation of DPL? |
cannot detect retroperitoneal injuries. |
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which modality is best for looking at penetrating back or flank trauma? |
CT because DPL cannot detect retroperitoneal injuries |
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what are some disadvantages of FAST? |
1. may be obscured by bowel gas and subcutaneous air. 2. misses bowel, diaphragm and pancreatic lesions 3. operator dependent. |
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what percentage of stab wounds cause intra-peritoneal injury? |
30% |
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what are the indications for laparotomy in patients with abdominal stab wounds? |
peritonism, haemodynamic instability, fascia penetraton and gunshot wound. |
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what is the overall accuracy of serial physical exams? |
94%
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what are the indications for laparotomy? |
1. Blunt abdominal trauma with positive FAST scan or clinical evidence of intra-peritoneal bleeding 2. positive DPL 3. hypotension with penetrating wound 4. gunshot wound traversing peritoneal cavity 5. Evisceration 6. bleeding from rectum, stomach or GIT 7. peritonitis 8. free air under the diaphragm 9. CT showing ruptured GIT, intraperitoneal bladder injure, renal pedicle injury |
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which hemidiaphragm is more often injured? |
the left |
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how does duodenal injury occur? |
unrestrained drives, often unrestrained frontal impact, handle bars off bike or direct blows to the abdomen. raised suspicion with blood gastric aspirate from DPL. |
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how do pancreatic injuries result and how should they be managed? |
direct epigastric blow. Not ruled out with normal serum amylase. Double contrast CT may miss injury up to 8 hours afterwards. Patient should be observed with repeat CT abode. |
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what is a usual associated injury with urethral injuries? |
anterior pelvic fracture. |
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which body wall changes indicate there may be hollow viscus injury? |
seat-belt sign and lumbar distraction fracture |
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what mechanisms cause pelvic ring fractures? |
motorcycle crashes, pedestrian vehicle crashes, direct crush injuries to the pelvis and fall from grater than 3.6m. |
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what is the mortality of pelvic fractures? |
1 in 6. closed with hypotension 1 in 4 and open book fractures 50%. |
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what are the four main patterns of injury with pelvic fractures? |
1. AP compression 2. lateral compression 3. vertical shear 4. complex |
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what happens with AP pelvic compression? |
disruption of the pubic symphysis and tearing of the posterior osseous ligamentous complex. opening of the pelvic ring can cause haemorrhage from the posterior pelvic venous complex. |
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how high is the mortality from lateral pelvic compression? |
not overly high since these generally remain closed fractures. |
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what is the management of pelvic fractures? |
pelvic binder, orthopaedic assessment, angio-embolic treatment for definitive management, transfer to trauma unit. |
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in what percentage of people have the left hemisphere as their centre of speech and language? |
85% of people who are left handed and virtually 100% of people who are right handed have the speech and language centre in the left hemisphere. |
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how can you calculate cerebral perfusion pressure? |
CPP=MAP-ICP |
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is underlying brain damage more severe in acute subdural haematomas or epidural? |
generally subdurals produce more damage since there is more underlying tissue damage. |
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how common are epidural haematomas? |
relatively uncommon occur in 0.5% of patients with brain injuries. Occur in 9% of patients who are comatose. |
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how common are subdural haematomas? |
more common that epidurals, they occur in about 30% of patients with severe brain injuries. |
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how common are cerebral contusions? |
present in about 20% to 30% of patients with brain injuries. |
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what percentage of patients with GCS 13 require have CT findings indicative of trauma? |
25% |
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what percentage of patients with GCS 13 require neurosurgical intervention? |
1.3% |
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what percentage of patients with GCS 15 have findings indicative of trauma? |
10% |
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what percentage of patients with GCS 15 require neurosurgical intervention? |
0.5% |
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which factors suggest high risk of findings of CT brain? |
GCS score less than 15 at 2 hours suspected open or depressed skull fracture basilar skull fracture vomiting (more than twice) age over 65 |
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which factors suggest moderate risk for brain injury? |
loss of consciousness (more than 5 minutes) amnesia before impact dangerous mechanism by motor vehicle |
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what is the management of a patient with a moderate brain injury? |
defined as a GCS of 9-12 10-20% of these patients lapse into coma at some point. They require frequent neuro obs and admission to HDU/ICU with repeat head CT 24 hours after initial scan. |
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what is the management of a patient with a severe brain injury? |
ABCDEs, primary and secondary survery. Mannitol, moderate hyperventilation and hypertonic saline. |
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what paCO2 should we aim for in patients with severe brain injury? |
35mmHg CO2. Hyperventilation paCO2<32mmHg should be used in caution with severe brain injury and only after acute neurological deterioration has occurred. |
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what are some other causes of reduced responsiveness in brain injury other than the primary injury? |
toxins (including drugs and alcohol), post octal phase if there has been a seizure? |
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what are the problems with hyperventilation and hypoventilation? |
hyperventilation tends to cause vasoconstriction and can propagate ischaemia, whereas hypoventilation tends to produce cerebral oedema which can worsen ICP. |
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what is the role of barbiturates in reducing ICP? |
they are useful in reducing ICP refractor to other measures. should not be used in hypotension and hypovolaemia. long half life, so may prolong determination of brain death. |
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what percentage of patients admitted with closed head injuries suffer from seizures? |
5% |
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what percentage of patients with severe head injury develop post-traumatic epilepsy? |
15% |
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what agents can be used to stop shivering? |
clonidine 150micrograms |
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what agent is generally used to control seizure activity? |
phenytoin, loading dose of 1g Iv at a rate of 50mg/min. maintenance dose is 100mg/8hours. |
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what can be done for prolonged seizures? |
general anaesthesia |
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what are the 4 Cs of increased density? |
1. contrast 2. clot 3. cellularity 4. calcification |
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what percentage of children with head/neck trauma get C spine fractures? |
1% |
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what percentage of fractures after trauma are in the C spine |
55%, 15% lumbar, 15% thoracic, 15% sacral |
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how does the spinal canal of an 8 year old differ from that of an adult? |
more flexible joint capsule, interspinous ligaments, flat facet joints, vertebral bodies wedged forwards and tend to slide forward with flexion. |
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why is the thoracolumbar junction more vulnerable to injury? |
there are stronger vertebrae inferior to this region? |
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where does the spinal cord originate from? |
from the base of the medulla oblongata |
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which spinal tracts can be assessed clinically? |
lateral corticospinal, spinothalamic and dorsal columns. |
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what is the classical history for a central cord syndrome? |
hyperextension of the C-spine in a patient with pre-existing cervical stenosis. often a forward fall involving facial impact. thought to be related to vascular compromise of the anterior spinal artery. |
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what are the features of anterior cord syndrome? |
paraplegia and loss of pain and temperature. |
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what is the pattern of recovery for central cord syndrome? |
lower extremities recovering first, bladder next, proximal upper extremities and hands last. |
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what are the features of Brown Sequard Syndrome? |
ipsilateral loss of motor fibres, position and vibration sense, contralateral loss of pain two levels below the injury. often caused by direct penetrating injury. |
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describe the presentation of atlanto-occipital dislocation. |
severe flexion and extension injury to the neck, causes severe neurologic injury with often quadriplegia and ventilator requirement. |
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what percentage of atlas fractures are associated with axis fractures? |
40% |
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atlas fractures represent what percentage of acute vertebral fracture? |
5% |
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how does a burst fracture occur? |
also known as a jefferson fracture, a burst fracture is due to severe axial loading |
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what is the bony result of a jefferson fracture? |
anterior and posterior rings are disrupted and the lateral mass goes to one side. |
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how often is spinal cord injury associated with an atlas fracture? |
rarely |
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how is a C1 fracture managed? |
although it may be stable, is presumed unstable until proven otherwise? |
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what is a C1 rotary subluxation? |
most often occurs in children. May be associated with respiratory disease or rheumatoid arthritis. Presents as persistent rotational torticolis. |
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what percentage of C spine injuries are C2 fractures? |
18% |
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what are the different types of odontoid fractures? |
type I - tip of the odontoid type II - base of the dens type III - odontoid fracture at base of dens extending obliquely into the axis |
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what type of fracture involves the posterior part of C2 |
Hangman fractures and bilateral fractures through the lateral masses or pedicles. |
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what is the most common level of vertebral fracture in adults? |
C5 |
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what are CT features of Hangman fractures? |
anterior angulation and excessive distance between the spinous processes of C1 and C2. |
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what is the association between neurologic injury and facet dislocation? |
very high |
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how are thoracic spinal fractures classified? |
1. anterior wedge compression 2. Burst injuries 3. Chance fractures 4. fracture dislocations |
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what causes anterior wedge compression fractures? |
flexion with significant axial loading. often a stable fracture because of the rigidity of the rib cage. |
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what causes burst fractures? |
vertical-axial compression |
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what causes chance fractures? |
they are transverse fractures through the vertebral body caused by flexion about an axis anterior to the vertebral column, such as in a motor vehicle accident where the patient is restrained by only a lap belt. often associated with abdominal visceral injury. |
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what causes thoracic spinal fracture dislocation? |
relatively rare, requires a lot of force, extreme flexion or blunt trauma to the spine. |
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what causes thoracolumbar junctional fractures? |
generally result from a combination of acute hyeprflexion and rotation. vulnerable to rotational movement and so logrolling should be performed with extreme care. |
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where does the spinal cord terminate? |
approximately L1, at this level, there may be |
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what fractures are most associated with vertebral vascular injuries? |
1. C1-C3 fracture 2. spine fracture with subluxation 3. fractures involving the foramen transversarium |
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what is the role of a semirigid collar? |
in some patients with soft tissue injury, it is impossible to perform the necessary flexion and extension manoeuvres, they should be in a semirigid collar for 2-3 weeks before retaking the images. |
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what percentage of patients with a C spine fracture will have a noncontiguous vertebral fracture? |
10%, thus they require imaging of the entire vertebral column |
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why should the limb be immobilised if vascular injury is suspected? |
haematoma needs to be compressed |
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what is commonly associated with fracture dislocation of the ankle? |
severe vascular injury |
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how should an amputated body part be transported? |
washed with an isotonic solution (Ringer's lactate) in sterile gauze that has been soaked in aqueous penicillin. The amputated part then transported in an insulated cooling chest with crushed ice. the amputated part must not be frozen. |
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what are common locations for compartment syndrome? |
lower leg, forearm, foot, hand, gluteal region and thigh |
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how is compartment syndrome diagnosed? |
clinically, with direct pressure measurement and delta P. when the difference between diastolic pressure and the compartment pressure is less than 30mmHg. If the intra-compartmental pressure is more than 30-45mmHg, then we also diagnose compartment syndrome. |
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what is the management of compartment syndrome? |
remove all constrictive dressings, splints and casts, monitor for 30-60minutes and if there is no improvement, then fasciotomy. Delayed fascitomy can be devastating and even cause renal damage. |
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how should one perform joint re-alignment? |
grasp and manually apply distal traction. |
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what are some of the complications of thermal injuries? |
dehydration, hypotension, rhabdomyolysis and cardiac dysrhythmias from electrical burns. |
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what characterises a first degree burn? |
E.g. a sunburn. Erythema, pain and absence of blisters. |
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what characterises a partial thickness burn? |
red or mottled appearance with swelling an blister formation, painful wet and even hypersensitive to air current |
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what characterises a full thickness burn? |
dark and leathery skin, may also appear translucent or waxy white, surface generally painless and dry. |
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at what level does carbon monoxide poisoning produce symptoms? |
at above 20% |
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what is the symptomatology of CO poisoning? |
headache and nausea 20-30%, confusion 30-40%, coma 40-60%, death >60% of blood concentration. |
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what is the role of oxygen in CO poisoning? |
the dissociation of CO is very slow (4 hours) breathing room air, whereas it reduced to 40 minutes with high flow oxygen. All patient suspected of CO poisoning should have high flow oxygen through a non-rebreather mask. |
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what role do ABGs play in CO poisoning? |
they establish a baseline from which improvement can be measured, however do not accurately estimate degree CO poising itself because 1mmHg of paCO2 correlated to 40% Hb saturation. |
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describe the definition and pathophysiology of smoke inhalation injury? |
diagnosed from history as inhalation of combustible products and from bronchoscopy as signs of smoke exposure below the vocal cords. causes an inflammatory response in the airways reduces oxygen exchange and can obstruct the airways. |
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what is the most reliable way to assess a circulating volume in a burnt patient? |
an indwelling catheter provided the patient is not on osmotic diuresis. |
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describe fluid resuscitation in burnt patients? |
they require 2-4ml of fluid per kg of body weight per percentage of BSA deep partial or full thickness burn over a 24 hour period. Give the first half over the first 8 hours and the second half over the following 16 hours. |
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how should fluids be titrated in burn patients? |
to urine output |
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how does fluid titration differ in children? |
they may require glucose as well. |
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what is the role of neutralising agents in chemical burns? |
No role. They have no advantage over water because they can create heat through reactions which further damage tissue. |
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what are the criteria for transfer to a burns hospital? |
partial thickness or full thickness >10%BSA, partial or full thickness involving face, ears, eyes, genitalia etc, full thickness in any age any size, significant electrical burns with complications, significant chemical burns, inhalation injury, burn in patient with pre-existing injury, burn with trauma, burn over joint surface, child with burn, long-term rehab etc needed. |
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what are the four types of frostbite? |
1. first degree - hyperaemia and oedema without necrosis 2. second degree - oedema and large clear vesicle formation 3. third degree: full thickness and subcutaneous necrosis 4. Fourth degree: down to bone and tendon with gangrene. |
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what are the leading causes of unsuccessful resuscitation in children? |
failure to secure the airway, support breathing and recognise and respond to intra-cranial bleeding. |
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what are some consideration in children who have sustained trauma? |
smaller body means more force per unit body area and more head injuries due to head size. skeleton incompletely calcified so underlying damage without overlying bone fracture. reduced surface area makes them more susceptible to hypothermia. |
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what are some important paediatric airway considerations? |
neutral position is better than the traditional "sniffing air" position and placement of a layer of padding beneath the infant or toddler's torso is often necessary to make the plane of the face parallel to the plan of the table. the airway is shorter and intubation of the main bronchi may result. |
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what drugs should be used for children requiring intubation? |
pre-oxygenation as always, atropine in infants less than 1 year of age to blunt the vagal response. midazolam 0.1mg/kg for sedation and succinylcholine (1mg/kd<10kg, 2mg/kg>10kg) and rocuronium (0.6mg/kg) can be used for paralysis. |
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what percentage of volume loss would be seen in a child to reduce his/her blood pressure? |
30% |
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what are the early signs in a child that he/she may be in shock? |
tachycardia and poor peripheral perfusion |
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what are some of the more subtle signs that a child is undergoing haemodynamic shock? |
1. progressive weakening of peripheral pulses 2. pulse pressure of less than 20mmHg 3. skin mottling 4. cool extremities compared with the torso |
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how does one calculate the mean systolic blood pressure for a child based on age? |
90mmHg + double the child's age. Diastolic should be about 2/3 of systolic |
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what are different means of estimating a child's weight? |
ask care giver, use length based approximation, finally agex2+10 |
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how are an infant's and baby's blood volume estimated? |
infant blood volume: 80mL/kg, child 70mL/kg |
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how are fluids given in children for resuscitation? |
in boluses of 20mL/kg often to a max of 60mL/kg. |
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which features in addition to seat-belt sign suggests intra-abdominal trauma? |
lumbar spine fracture, intra-peritoneal fluid, pulse over 120bpm |
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how many children undergoing CT scan develop fatal cancers? |
1 in 1000 |
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what should the next step be in a child with abdominal fluid found on FAST scan? |
assess haemodynamic status, if style, CT scan and monitor as splenic bleeding and liver bleeding may often be self limiting. If there is significant compromise, then urgent laparotomy is required. |
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How is the child's brain different anatomically from the adult's? |
it goes rapidly, doubles in size in the first 6 months. Achieves 80% of the adult size by age 2. the subarachnoid space is relatively smaller, offers less protection. parenchymal damage is more common. cerebral blood flow increases to twice that of adult levels by age 5 and then decreases. children are very susceptible to hypoxia and hypercarbia. |
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why are children able to compensate more readily than adult brains in raised intra-cranial pressure? |
the open fontanelle |
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in a child with suspected brain injury who is vomiting severely what must be done in addition to CT head? |
gastric decompression |
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what drugs are used in children with head injuries? |
1. phenobarbital 10-20mg/kg/dose 2. diazepam 0.1-0.2mg/kg/dose slow IV bolus 3. phenytoin 15 to 20mg/kg 4. Hypertonic saline 3% 3to5ml/kg 5. Mannitol 0.5 to 1.0g/kg only used if incontrovertible signs of transtentorial herniation |
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in children where are most C spine fractures? |
occiput to C3. this is because this is the position of the fulcrum in these children, this is because of the larger occiputs in children. |
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what is an important radiographic consideration when examining C spine radiographs in children? |
up to 40% of children younger than 7 years of age show anterior displacement of C2 relative to C3 and 20% of children exhibit this phenomenon. |
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how do fractures of long bones differ in children from adults? |
they generally do not tend to cause the same degree of haemodynamic compromise, closed femur fracture in a child will only reduce haematocrit by four points. |
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what are some important points about supracondylar fractures? |
supracondylar fractures at the elbow or knee have a high propensity for vascular injury as well as growth plate injury. |
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what are the rates of underlying disease in elderly patients sustaining trauma, and how effective is resuscitation? |
9.2% of older patients have pre-existing disease. Over 80% of injured older adults return to their pre-morbid level of functioning after resuscitation. |
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which common medications are relevant in trauma? |
anticoagulants increase bleeding, beta blockers blunt the catecholamine response. |
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what is the leading cause of death due to injury in the elderly? |
thermal injury |
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how big a role does alcohol play in the elderly? |
1/3 of elderly adults are injured in he context of having alcohol |
